Healthcare Provider Details

I. General information

NPI: 1174786560
Provider Name (Legal Business Name): TRACI M KISTLER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2008
Last Update Date: 07/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 W 22ND ST ROUTING NUMBER 114
SIOUX FALLS SD
57105-1305
US

IV. Provider business mailing address

2501 W 22ND ST ROUTING NUMBER 114
SIOUX FALLS SD
57105-1305
US

V. Phone/Fax

Practice location:
  • Phone: 605-336-3230
  • Fax: 605-333-6883
Mailing address:
  • Phone: 605-336-3230
  • Fax: 605-333-6883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberR028634
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: